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Regional Block Anesthesia and Eversion Technique for Treatment of a Symptomatic, Long Length, High Carotid Artery Lesion
Avianne P. Bunnell, MD, Mathew Wooster, MD.
Medical University of South Carolina, Charleston, SC, USA.

Regional Block Anesthesia and Eversion Technique for Treatment of a Symptomatic, Long Length, High Carotid Artery Lesion
Objectives: Surgical exposure for pathologic lesions extending into the distal extracranial internal carotid artery is more challenging and less frequently performed than standard carotid endarterectomy. Careful attention must be paid to additional nervous structures and use of the eversion technique can make performance of the procedure easier and more expeditious than the more frequently performed patch endarterectomy.
Methods: This case demonstrates the use of a superficial cervical plexus regional block combined with local anesthetic to allow direct neurological monitoring while performing an eversion endarterectomy with high anatomic exposure. Pertinent technical details described include division of the digastric muscle, mobilization of the hypoglossal nerve via ligation of the sling vessels, and protection of the glossopharyngeal nerve as it exits near the styloid process. Intraoperative completion duplex is used as well to confirm absence of kinking, residual flap, or residual significant stenosis.
Results: A 64 year old man with high grade, symptomatic carotid artery stenosis in a tortuous vessel with a long, high lesion extending to the C2 vertebral body was treated with carotid endarterectomy. Using regional/local anesthesia and an eversion technique, he underwent a successful eversion endarterectomy. His surgical drain was removed and the patient was discharged on post operative day one without any complications, to include no transient neurological deficits or nerve injuries. He is now one year out and remains asymptomatic with <50% stenosis on his most recent surveillance duplex.
Conclusions: Awake/regional block anesthesia can be used to safely perform even high carotid artery exposure for the performance of endarterectomy. Eversion technique provides a method to simplify the technical aspect of suturing the anastomosis as well as reducing the length of anastomosis when treating long lesions.


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